Clinical Reasoning

A nurse’s clinical reasoning ability is a key factor in the provision of quality care and the prevention of adverse patient outcomes. This unique book provides a series of authentic, engaging and meaningful scenarios that will guide you through the clinical reasoning process while challenging you to think critically and creatively about the nursing care you provide. It will promote deep learning and opportunities for you to rehearse how you will respond to real clinical situations in ways that are both person-centred and clinically astute.

Chapter 1
Clinical reasoning: What it is and why it matters 
Tracy Levett-Jones and Kerry Hoffman
Introduction
What does it mean to ‘think like a nurse’?
What is clinical reasoning?
Why is clinical reasoning important?
The clinical reasoning process
Clinical reasoning and critical thinking
Questioning assumptions and understanding errors
Learning activity
Further reading
References

Chapter 2
Caring for a person experiencing an adverse drug event
Tracy Levett-Jones and David Newby
Introduction
Scenario 2.1 What did happen…
Reflection
Scenario 2.2 What might have happened…
Setting the scene
Changing the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Further reading
References
Photo credits

Chapter 3
Caring for a person with fluid and electrolyte imbalance 30
Tracy Levett-Jones, Kerry Hoffman, Jennifer Dempsey and Peter Sinclair
Introduction
Scenario 3.1 The fluid shift begins…
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 3.2 The pendulum swings in the other direction…
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References

Chapter 4
Caring for a person experiencing respiratory distress and hypoxia 54
Kerry Hoffman, Raelene Kenny and Jennifer Dempsey
Introduction
Scenario 4.2 Caring for a person with hypoxia and hypoxaemia
Setting the scene
Person-centred care
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 4.2 Caring for a person with respiratory distress…
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References
Photo credit

Chapter 5
Caring for a person with a cardiac condition
Kerry Hoffman, Jennifer Dempsey and Raelene Kenny
Introduction
Scenario 5.1 Caring for a person with ischaemic chest pain
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 5.2 Caring for a person with heart failure
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References
Photo credit

Chapter 6
Caring for a person with an acquired brain injury
Kerry Hoffman and Nathan Haining
Introduction
Scenario 6.1 Caring for a person with an acquired brain injury and altered level of consciousness
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 6.2 Caring for a person recovering from a stroke
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References
Photo credit

Chapter 7
Caring for a ‘challenging’ patient
Teresa Stone and Rachel Rossiter
Introduction
Scenario 7.1 Caring for a person with a substance abuse problem
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 7.2 The story unfolds: More than just substance abuse
Changing the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Further reading
References
Photo credit

Chapter 8
Caring for a person with an autoimmune condition
Rachel Rossiter and Teresa Stone
Introduction
Scenario 8.1 Caring for a person with scleroderma
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 8.2 The emotional impact of living with a chronic autoimmune condition
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References
Photo credit

Chapter 9
Caring for an older person with altered cognition
Sharyn Hunter and Frances Dumont
Introduction
Scenario 9.1 Caring for an older person with delirium
The aetiology and pathogenesis of altered cognition in older people
The epidemiology of the 4Ds
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 9.2 Caring for an older person with dementia
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Reflect
Epilogue
Further reading
References
Photo credit

Chapter 10
Caring for a person experiencing pain
Tracy Levett-Jones and Caroline Phelan
Introduction
Scenario 10.1 Caring for a person experiencing acute pain
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 10.2 Caring for a person experiencing persistent pain
Changing the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Further reading
References

Chapter 11
Caring for a child with type 1 diabetes 204
Loretto Quinney, Kerry Reid-Searl, Lea Vieth and Bree Walker
Introduction
Scenario 11.1 Caring for a child diagnosed with type 1 diabetes
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 11.2 Caring for a child with diabetic ketoacidosis (DKA)
Changing the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References

Chapter 12
Caring for a person receiving blood component therapies 224
Jennifer Dempsey and Kerry Hoffman
Introduction
Scenario 12.1 Caring for a person requiring an emergency transfusion of packed red blood cells
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 12.2 Caring for a person undergoing a transfusion of platelets and fresh frozen plasma
Changing the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References
Photo credits

Chapter 13
Caring for a person requiring palliative care 244
Pamela van der Riet and Victoria Pitt
Introduction
Scenario 13.1 The palliative care journey begins
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Scenario 13.2 The palliative care journey comes to an end
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Epilogue
Further reading
References

Chapter 14
Ethical and legal dimensions of clinical reasoning: Caring for a person who is refusing treatment 266
Lorinda Palmer
Introduction
Scenario 14.1 The night before Christmas...
Setting the scene
Values
Person-centred care – who is George?
Scenario 14.2 Christmas morning...
Setting the scene
1. Consider the patient situation
2. Collect cues / information
3. Process information
4. Identify the problem / issue
5. Establish goals
6. Take action
7. Evaluate
8. Reflect
Further reading
References

Appendices
I: Cognitive screening tools
II : Brief pain inventory
III : Care plan for a person with scleroderma
IV: Symptom assessment scale – Palliative care outcomes collaboration

Glossary
Index

• Each chapter includes two linked clinical scenarios. A sequential, step-through approach is used and an ‘unfolding story’ presented. Web links to relevant resources are included. A series of multiple choice, true/false, rank and sort, and short answer questions are provided and you will be asked to make decisions at critical junctures. The scenarios are an opportunity to test out your knowledge, to make mistakes and to learn from those mistakes.
• The scenarios have been adapted from real clinical situations and are of varying levels of complexity. In this instance complexity refers not to acuity but to clinical situations for which there is not an immediate and pre-defined response. This includes patient encounters that require the nurse to thoughtfully collect appropriate information, to interpret and make sense of that information, and to plan, initiate, evaluate and reflect on the effectiveness of nursing interventions.
• The scenarios portrayed take place in a range of health care and community settings.
• While most chapter emphasise how effective clinical reasoning skills can help you recognise and manage patient deterioration early and, in effect, “rescue” the patient; Chapter 14 considers the ethical implications of withholding potentially lifesaving treatments when an attempt to “rescue” may not be in the person’s best interests or does not accord with their wishes. These are some of the most difficult clinical decisions that can be made and require effective clinical and moral reasoning skills.
• The selection of scenarios is deliberate and framed by Australia’s National Health Priority Areas. The clients/patients profiled are of different ages and from different cultural backgrounds; and the key concepts that feature in the book are linked to patient safety and quality care.

Key Pedagogy:

• Answer responses are provided online as formative feedback. Please note that in some cases a variety of responses is acceptable.
• Learning outcomes are listed at the beginning of each chapter and will help orientate you to what you will learn.
• Key concepts integrated throughout this book include person-centred care, holistic practice, therapeutic, intra and interprofessional communication, cultural sensitivity, and patient safety. The integration of these concepts will help you to transfer your learning to new clinical situations leading to application and a deeper understanding. Pathophysiology and safe medication practices are also integrated throughout the book. Additionally, there are key concepts linked to each chapter. 
• Suggested readings are provided and you can either read in preparation for undertaking the learning activities or challenge yourself by seeing how much you already know. Specific readings are provided from LeMone and Burke’s Medical-surgical nursing: Critical thinking in client care (Australian ed), Kozier and Erb’s Fundamentals of Nursing and other relevant resources; however, the same information can be accessed in most foundational or medical surgical textbooks. Additional readings are provided at the end of each chapter and these will help you to build on your knowledge about topics of interest.
• Reflective thinking is the final stage of the clinical reasoning cycle and in order for you to maximise your learning guided reflection questions are provided at the end of each scenario. Answers to these questions are not provided as their purpose is to help you think broadly, critically and creatively about what you have learned and most importantly, how your learning will inform you future practice. These questions may also be used to design assignment questions, for tutorial discussion, or to structure debriefing following simulation sessions.
• A glossary of terms is provided online and at the end of the book.

Tracy Levett-Jones, PhD, RN, MEd & Work, BN, DipAppSc(Nursing), is the Deputy Head of School (Teaching and Learning) in the School of Nursing and Midwifery at the University of Newcastle. Her research interests include: clinical reasoning, clinical education, belongingness, interprofessional communication, simulation and patient safety. Tracy’s doctoral research explored the clinical placement experiences of students in Australia and the United Kingdom. She has a broad clinical background and prior to her academic career worked as a nurse educator, nurse manager and clinician. Tracy has authored three books on clinical education, twelve book chapters and more than 50 peer reviewed journal publications. She has been awarded eight teaching and learning awards including the 2010 Pearson/Australian Nurse Teacher Society Nurse Educator of the Year Award and an Australian Learning and Teaching Council Award for Teaching Excellence.

Contributors

Dr Jennifer Dempsey, DN, RN, RPN, M Nurs. Studies, Grad Dip Nurs
Senior Lecturer, Director of Clinical Education, The School of Nursing & Midwifery, The University of Newcastle

Ms Frances Dumont, RN, MSN, BN, BEd
Dementia Delirium Clinical Nurse Consultant, Hunter New England Health 

Mr Nathan Haining, RN, BN, Grad cert. Crit care
Clinical Nurse Educator, Neuroscience, Westmead Hospital

Dr Kerry Hoffman, RN, BSc, Grad Dip. Ed., Dip. Health Sc., MN, PhD
Lecturer, The School of Nursing & Midwifery, The University of Newcastle

Dr Sharyn Hunter, PhD, RN, BSc( Hons),  Grad Cert(Aged Care) Grad Cert Tertiary Teaching
Lecturer, The School of Nursing & Midwifery, The University of Newcastle 

Ms Raelene Kenny RN, MNursing (Critical Care), GradCertEd (Adult & Org Learning), GradCert Tertiary Teaching
Lecturer, The School of Nursing & Midwifery, The University of Newcastle 

Professor Tracy Levett-Jones, PhD, RN, MEd & Work, BN, DipAppSc(Nursing)
Deputy Head of School (Teaching and Learning), The School of Nursing & Midwifery, The University of Newcastle

Associate Professor David Newby, BPharm, PhD
Acting Discipline Lead, Clinical Pharmacology, The School of Medicine and Public Health
The University of Newcastle

Ms Caroline Phelan, RN, MPH, BN, PhD candidate
Clinical Nurse Consultant Pain Management, Hunter Integrated Pain Service
 
Ms Lorinda Palmer, MN, RN, BSc., Dip. Ed, Grad Dip (Nurs)
Lecturer, The School of Nursing & Midwifery, The University of Newcastle, PhD candidate

Ms Victoria Pitt, RN, MNur (Research), Grad Dip Nurs (Pal.care), Grad Cert Tert Teaching, Dip ApSc (Nursing), PhD candidate
Lecturer, The School of Nursing & Midwifery, The University of Newcastle

Ms Loretto Quinney, RN,RM,CCRN,BaApp.Sc,Grad Cert Mng
Lecturer, The School of Nursing and Midwifery, CQUniversity
 
Dr Rachel Rossiter, D.HSc, RN, MN (NP), M.Counselling, B.Counselling, B.Hlth Sc
Director Postgraduate Coursework Programs, The School of Nursing & Midwifery, He University of Newcastle

Mr Peter Sinclair, RN, BN, Renal Cert, MPhil candidate
Lecturer, The School of Nursing & Midwifery, The University of Newcastle
Chair, The Nephrology Educators Network

Dr Teresa Stone, PhD, RN, RMN, BA M Health Management, GradCert Tertiary Teaching
Bachelor of Nursing Program Convenor, The School of Nursing & Midwifery, The University of Newcastle

Dr Kerry Reid-Searl, PhD,RN,RM,BHlth Sc,MClin Ed.
Assistant Dean Simulation, The School of Nursing and Midwifery, CQUniversity
 
Associate Professor Pamela van der Riet, PhD, RN, MEd , BA Dip ED (Nursing), ICU/CCU cert
Deputy Head of School, The School of Nursing & Midwifery, The University of Newcastle

Ms Lea Vieth, RN, BN
Paediatric Nurse, Rockhampton Hospital

Ms Bree Walker, RN, BN
Nurse Educator, Paediatrics, Rockhampton Hospital